HOME Form Page: ApplicationForm Date of Application Application For Employment Last 4 digits of Social Security No Last Name First Name Middle Name Address (Street number and name) City County State Zip Code Phone (Home or where you can be reached) Business Phone Email Availability Are you currently employed? Are you related by blood or marriage to any person now working for HSS Yes No Yes No If yes, give name, relationship to you If subject to Military Selective Service registration, certify compliance by initialing the box I am available to work Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mornings Noons Evenings Nights My availability above is flexible Ideal # of hours I’d like to work per week* Will you accept work anywhere in Wake, Cumberland, and Harnett County.? Yes No (If no, list below the towns/cities in which you would be willing to work.) Jobs Applied For Enter below the specific title(s) of the job(s) for which you are applying (i.e. RN, LPN, CNA). 1 2 Progress: 0% Page 1 of 5 Built with Simfatic Forms custom contact form builder.